Nursing Diagnosis for Bowel Obstruction

1 I'm having trouble finding an accurate Nursing Diagnosis for my patient. She was admitted for Bowel Obstruction and Hypotension. Abd is distended, but not firm. Patient c/o tenderness only when abd is palpitated. NGT to intermittent suction... which later I had to insert a new one because it was pulled out. The patient is a Diabetic and since admission to the hospital she has had repeated low blood sugars and been given D50 constantly. The doctor only has her on NS @ 125 and when I brought it to the attention of the nurse that the patient may need to be on D5NS or D5 1/2 NS to keep her blood sugars/electrolytes stable, she just said... well that's what he ordered. On my second day to care for the patient, as soon as I went into the room, I noticed the NGT was misplaced again! Her oral mucosa is dry and lips are chapped. I had her remove her dentures to prevent any further irritation. The patient said that she just doesn't know if she can go on anymore. On her CT scan it shows ischemic small bowel and small tumor on the outside of her bowel in the messentery.

I have to have a physical and a psycosocial diagnosis. I want one that would pertain to the NGT, but I can't find anything that really fits my patient. Can someone please help?

You are on the right track. What you need to do next is make a list of all the abnormal data. Try to group it by body systems, or symptoms, that seem kind of similar. Every nursing diagnosis has a set of signs and symptoms called defining characteristics. What you have to do is use a nursing diagnosis reference to find nursing diagnoses that have some of the same symptoms your patient has. Some you may recognize as belonging with certain diagnoses. Some you may not. Try your hand at this first and if you are still having trouble finding matches, ask, and I will help you.

Thanks! I was thinking about...
"Deficit fluid volume r/t active fluid loss 2nd to continuous nasogastric suction AEB electrolyte imbalance"
I don't think that I mentioned that her Na+ was low and K+ was high. She has non-pitting edema on her back and upper arms, but no where else. Or maybe I should do "Fluid volume excess"? Even though she does have the NGT she still is retaining fluid instead of losing it. Her I/O's aren't matching up with almost a 1000mL difference. That's why I asked why she wasn't on 1/2 NS instead?

do you have a pathophysiology textbook? with bowel obstructions, there is fluid loss because fluid builds up in the bowel. that's where your patient's abdominal distension is most likely coming from. that fluid is lost because it cannot be absorbed back into the body. and, it's rich with electrolytes. double whammy. so, deficient fluid volume r/t active fluid loss is correct but it is not due to nasogastric suction. it is due to the bowel obstruction. what do they think is causing this bowel obstruction? bowel obstructions don't show up out of the blue in healthy people. did she have prior abdominal surgery? have they confirmed a malignancy? your aeb items must be the symptoms, or evidence that support the problem (in this case, the deficient fluid volume). how does an imbalance of electrolytes, specifically hyponatremia and hyperkalemia, cause dehydration? doesn't. but, that's basically what your statement is saying. the symptoms of this diagnosis are listed under the heading "defining characteristics" on these webpages. since the definition of this diagnosis specifically says it is referring to dehydration, i would say that any signs or symptoms of dehydration not listed by nanda would also be acceptable.

why, beside electrolyte disturbances, do people retain fluid and have non-pitting edema on back and upper arms? pitting edema of the back and arms is odd and seems more like a circulation problem. i would think that something else is going on. did this lady have a mastectomy or a splenectomy in the past? what other things went on in her past medical history? hypotension would suggest that her blood is not being pumped around very efficiently which could result in edema. knowledge of the underlying pathophysiology of patient's medical conditions is very important in determining etiologies of nursing diagnoses.

your patient also has acute pain. it doesn't matter that it is only when the abdomen is palpated. pain is pain. i had colon cancer and one of the things my oncologist never fails to do is assess for or treat abdominal pain no matter how insignificant it might be.

what do you want to do about her dry lips and mouth (impaired oral mucous membranes)?

what about her depression (anticipatory grieving, hopelessness, powerlessness)?

Yes, she's had a left mastectomy. She has a hx of hypertension, but was experiencing hypotension upon admission to the hospital. She's had umbilical hernia repair and has had a hx on bowel obstructions. Yes there is a tumor, not in her bowel but on the outside of it.

that is all important information that contributes to and helps explain the pathophysiology of some of these abnormal things you are seeing in this patients assessment and you can't ignore it.

with mastectomies lymph nodes are also removed making edema of the arm on the affected side a potential complication. if this patient is immobile it increases the likelihood of this happening since the lymphatic system runs parallel to the circulatory system. it also begs the question of metastasis. breast cancer often metastasizes to the nearby lungs and bone. this brings in the issue of hypotension.

any time there has been previous abdominal surgery and a history of bowel obstructions there is a risk for obstructions happening again. a tumor in the mesentery is bad news: (1) they are hard to detect (2) when they are found they are generally already well established, and (3) don't you suspect she was told her diagnosis by the doctor if she's making statements like she doesn't know if she can go on anymore? did anyone ask her?

your job is to put this information together, determine her nursing problems, and develop intelligent nursing interventions and outcomes based on what you now know.

i asked those questions because they were ones i would have been asking. of course i have many years of experience so i have a better idea of what to ask. in time and with experience, so will you. i wanted you to get an idea of how you need to be thinking when you are caring for patients. you have to always be thinking "why is this happening to her?" and hunt down the reasons. assessment and information gathering (and putting it together) is a never-ending pursuit. you have to be like a detective always looking for information and clues and trying to figure out how they fit into the bigger picture. making those connections helps in planning nursing care.

now, some of this patient's oral and throat discomfort is from the presence of the n/g tube (look up the effects of a foreign body on the body--inflammation and immune response: http://allnurses.com/forums/f50/hist...ct-244836.html). but the suctioning out of gastric secretions while it may contribute to some electrolyte imbalances (you need lab values to support this), her fluid losses are due to fluid collecting and being lost in her intestines secondary to the bowel obstruction. that fluid collecting in her bowel is only coming out through (1) the anus, (2) the front end via a cantor tube, (3) on the surgical table if or when she gets opened up.